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psnet.ahrq.gov/node/50623/psn-pdf
November 06, 2019 - Adverse Events in Anesthesia: An Integrative Review.
November 6, 2019
Lemos C de S, Poveda V de B. Adverse Events in Anesthesia: An Integrative Review. J Perianesth Nurs.
2019;34(5):978-998. doi:10.1016/j.jopan.2019.02.005.
https://psnet.ahrq.gov/issue/adverse-events-anesthesia-integrative-review
This integrative …
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psnet.ahrq.gov/node/60677/psn-pdf
July 08, 2020 - Optimizing patient safety through system strategies and
patient engagement.
July 8, 2020
Rooprai P, Mistry N. Patient Saf Qual Healthc. June 23, 2020.
https://psnet.ahrq.gov/issue/optimizing-patient-safety-through-system-strategies-and-patient-engagement
Health systems are complex environments that require integra…
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psnet.ahrq.gov/node/41396/psn-pdf
May 23, 2012 - In search of common ground in handoff documentation in
an intensive care unit.
May 23, 2012
Collins S, Mamykina L, Jordan D, et al. In search of common ground in handoff documentation in an
Intensive Care Unit. J Biomed Inform. 2012;45(2):307-15. doi:10.1016/j.jbi.2011.11.007.
https://psnet.ahrq.gov/issue/search-c…
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psnet.ahrq.gov/node/45401/psn-pdf
August 17, 2016 - A better safety net for young doctors.
August 17, 2016
Landro L. Wall Street Journal. August. 8, 2016.
https://psnet.ahrq.gov/issue/better-safety-net-young-doctors
First-year residents may be reluctant to ask for assistance due to factors such as peer pressure to
demonstrate competency. This newspaper article repo…
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psnet.ahrq.gov/node/39554/psn-pdf
October 13, 2010 - Utilizing information technology to mitigate the handoff
risks caused by resident work hour restrictions.
October 13, 2010
Bernstein J, MacCourt DC, Jacob DM, et al. Utilizing information technology to mitigate the handoff risks
caused by resident work hour restrictions. Clin Orthop Relat Res. 2010;468(10):2627-32.…
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psnet.ahrq.gov/node/42943/psn-pdf
April 12, 2014 - Doing right by our patients when things go wrong in the
ambulatory setting.
April 12, 2014
Schiff G, Griswold P, Ellis BR, et al. Doing right by our patients when things go wrong in the ambulatory
setting. Jt Comm J Qual Patient Saf. 2014;40(2):91-96.
https://psnet.ahrq.gov/issue/doing-right-our-patients-when-thin…
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psnet.ahrq.gov/node/45998/psn-pdf
April 19, 2017 - Learning and mindfulness: improving perioperative
patient safety.
April 19, 2017
Graling PR, Sanchez JA. Learning and mindfulness: improving perioperative patient safety. AORN J.
2017;105(3):317-321. doi:10.1016/j.aorn.2017.01.006.
https://psnet.ahrq.gov/issue/learning-and-mindfulness-improving-perioperative-patie…
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psnet.ahrq.gov/node/50381/psn-pdf
September 25, 2019 - Error disclosure and apology in radiology: the case for
further dialogue.
September 25, 2019
Brown SD, Bruno MA, Shyu JY, et al. Error Disclosure and Apology in Radiology: The Case for Further
Dialogue. Radiology. 2019;293(1):30-35. doi:10.1148/radiol.2019190126.
https://psnet.ahrq.gov/issue/error-disclosure-and-a…
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psnet.ahrq.gov/node/764408/psn-pdf
March 02, 2022 - Ensuring critical instruments and devices are appropriate
for reuse.
March 2, 2022
Quick Safety. February 14, 2022;(64):1-3.
https://psnet.ahrq.gov/issue/ensuring-critical-instruments-and-devices-are-appropriate-reuse
Complete, appropriate reprocessing and sterilization of reusable medical instruments and devices …
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psnet.ahrq.gov/node/849338/psn-pdf
May 24, 2023 - The impact of language barriers on patient care: a
pharmacy perspective.
May 24, 2023
Patel J. PM Healthcare Journal. Spring 2023(4):5-18.
https://psnet.ahrq.gov/issue/impact-language-barriers-patient-care-pharmacy-perspective
Language discordance is known to degrade medication safety. The article discusses an exa…
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psnet.ahrq.gov/node/47413/psn-pdf
September 26, 2018 - Please, write to me. Writing outpatient clinic letters to
patients. Guidance.
September 26, 2018
London, UK: Academy of Medical Royal Colleges; September 2018.
https://psnet.ahrq.gov/issue/please-write-me-writing-outpatient-clinic-letters-patients-guidance
Miscommunication due to clinician use of medical jargon an…
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psnet.ahrq.gov/node/840164/psn-pdf
November 16, 2022 - Medical error and vulnerable communities.
November 16, 2022
Jean-Pierre P. Boston U Law Rev. 2022; 102(1):327-392.
https://psnet.ahrq.gov/issue/medical-error-and-vulnerable-communities
Bias and discrimination are receiving overdue attention as primary barriers to patient safety. This article
discusses medical erro…
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psnet.ahrq.gov/node/50433/psn-pdf
September 04, 2019 - In men, it's Parkinson's. In women, it's hysteria.
September 4, 2019
Armstrong D. ProPublica. August 23, 2019.
https://psnet.ahrq.gov/issue/men-its-parkinsons-women-its-hysteria
Implicit biases can affect communication, diagnosis, and treatment decisions. This news article reports the
experience of a neurologist a…
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psnet.ahrq.gov/node/861776/psn-pdf
January 31, 2024 - The Sunday story: when hospitals don't say sorry.
January 31, 2024
Rascoe A, Gorenstein D. National Public Radio. January 21, 2024.
https://psnet.ahrq.gov/issue/sunday-story-when-hospitals-dont-say-sorry
Openness about making mistakes is a challenge in health care due to fear of litigation and career damage.
This …
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psnet.ahrq.gov/node/44283/psn-pdf
July 15, 2015 - An analysis of near misses identified by anesthesia
providers in the intensive care unit.
July 15, 2015
Lipshutz AKM, Caldwell JE, Robinowitz DL, et al. An analysis of near misses identified by anesthesia
providers in the intensive care unit. BMC Anesthesiol. 2015;15:93. doi:10.1186/s12871-015-0075-z.
https://psne…
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psnet.ahrq.gov/node/44312/psn-pdf
November 06, 2015 - Beyond the team: understanding interprofessional work
in two North American ICUs.
November 6, 2015
Alexanian JA, Kitto S, Rak KJ, et al. Beyond the Team: Understanding Interprofessional Work in Two North
American ICUs. Crit Care Med. 2015;43(9):1880-6. doi:10.1097/CCM.0000000000001136.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/50457/psn-pdf
October 09, 2019 - Combined SNA and LDA methods to understand adverse
medical events
October 9, 2019
Zhu L, Reychav I, McHaney R, et al. Combined SNA and LDA methods to understand adverse medical
events. Int J Risk Saf Med. 2019;30(3):129-153. doi:10.3233/JRS-180052.
https://psnet.ahrq.gov/issue/combined-sna-and-lda-methods-understa…
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psnet.ahrq.gov/node/45229/psn-pdf
July 13, 2016 - The WakeWings journey: creating a patient safety
program.
July 13, 2016
Mills E. The WakeWings Journey: Creating a Patient Safety Program. AORN J. 2016;103(6):636-9.
doi:10.1016/j.aorn.2016.04.004.
https://psnet.ahrq.gov/issue/wakewings-journey-creating-patient-safety-program
Successful and sustainable implementa…
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psnet.ahrq.gov/node/36130/psn-pdf
September 29, 2010 - OZIS and the politics of safety: using ICT to create a
regionally accessible patient medication record.
September 29, 2010
Stoop AP, Bal R, Berg M. OZIS and the politics of safety: using ICT to create a regionally accessible
patient medication record. Int J Med Inform. 2007;76 Suppl 1:S229-35.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/41156/psn-pdf
March 02, 2012 - The implementation of a perioperative checklist increases
patients' perioperative safety and staff satisfaction.
March 2, 2012
Böhmer AB, Wappler F, Tinschmann T, et al. The implementation of a perioperative checklist increases
patients' perioperative safety and staff satisfaction. Acta Anaesthesiol Scand. 2012;56(…